The Hungarian National Programme for Mental Health and its relation to the WHO-initiatives

In this article we shall examine the connections and disconnections between WHO's Mental Health Declaration & Action Plan and the Hungarian National Programme for Mental Health (NPMH).

Prior to NPMH, Hungary had not had any national programme on mental health issues, except a Parliamentary Resolution on the National Strategy for the Reduction of Drug Problem in 2000, and the National Alcohol Policy that was developed between 2004–2005 and adopted but never implemented by the Public Health Interministerial Committee.
MHD&AP attracted attention to a topic that was previously neglected from the national policy agenda. According to the Biannual Collaborative Agreement, the Hungarian Government agreed with WHO to develop “national strategies for mental health and substance use disorders based on WHO European documents”, hence NPMH – both its first and second draft – identifies MHD&AP as its primary international antecedent.

Still, WHO has marginal appearance in the documents with surprisingly few direct references. In the more than 100 pages long version of NPMH there are only 8 direct references to WHO, only one of which is a reference to NPMH&D. Six out of the remaining seven references can be classified as embodied knowledge according to the definition of Smith and Freeman (2008, 11), “knowledge that hinges on the authority of the actor who produces the knowledge and the embodiment of their knowledge within particular textual forms”. As it is evident from the following quotes, WHO’s role in the text is to bolster up the arguments by its authority:

“According to the prediction of the WHO, the frequency and burden of the mental breakdowns will increase in the future…”.

“According to the WHO, the social, environmental and economic factors of mental health are the following...”.

“According to the prognosis of WHO the frequency and burden of mental disorders will grow in the future…”.

There is only one occasion when the authors drew on an instrument that had been created by WHO: in the case of the reference to WHO Welfare Index.

If we consider the topics that are prioritized in MHD&AP, we find that NPMH reviewed all the prioritized areas of the WHO documents; the Hungarian documents, however, lay great emphasis on the need of the institutional development of psychiatric service. Comparing the intentions of the WHO and the Hungarian documents, it becomes evident that the accents have been shifted. There are emphasized issues in MHD&AP which are present in the Hungarian documents, but with much lesser significance. For example, in the first version of NPMH the problem of stigma, or the involvement of the users of mental health services and their families and carers are clearly not priorities. This changed somewhat in the second version, which – with an explicit reference to the European Pact – includes a short-term priority list that is identical to that of the European Pact, which includes stigma and social exclusion. Another issue that has a great significance in the WHO documents but was understated in the Hungarian National programme is prevention. One of the authors explained the neglect of prevention as follows:

”It is obvious that we are not talking about the same conditions in the case of, let’s say, the Netherlands, or even Britain and Hungary. In some regions of Hungary, the psychiatric service is on the level of a third world country. I agree that it is not right to set prevention against medical intervention, I do not believe that mental health education, or the struggle against work related stress is not important, but one must see clearly that prevention is very expensive, like a Mercedes or another luxury car. Even in the USA these programmes were stopped, because they could not finance them. And these programmes have very poor efficiency, one cannot really measure their effects” (A leader of HPA).

Community psychiatry – one of the fundamental elements of WHO Mental Health initiatives – is in its infancy in Hungary. Although it is often mentioned in the document, but only at a rhetoric level, without any actual plan about how this new paradigm will be introduced and realized. As we are going to see later in the light of the criticisms on NPMH, even though the Hungarian documents bring out certain WHO-inspired mental health policy issues, it is questionable to what extent they were actually internalized by the authors.

“At the time when we were writing this Programme, we did not know that the National Institute of Psychiatry and Neurology (OPNI, Budapest) would be shut down shortly. In the programme we wrote that a shift from large psychiatric institutions to community-based services would be recommended. Now we are hesitant about whether it was a good idea to include this recommendation into the document. A lot of people disapproved of this. Also we will never know whether we contributed to the close-down of OPNI with the Programme” (An author of NPMH).

Ironically, in the course of the closing down of the largest Hungarian mental health institution, the National Institute of Psychiatry and Neurology (OPNI, Budapest) in 2007, no reference was made to professional conviction about the necessary shift from asylum-like mental health institutions to community psychiatry, rather the financial rationalization argument in the Health Care System was adduced.
Hungarian psychiatric institutions are in great need of development. As a 1997 document, the Human Rights & Mental Health: Hungary, produced by Mental Disability Rights International pointed out, there were significant malfunctions in the Hungarian mental health system, a lot of which still exist. The discourse about the mental health reform has stayed within the framework of the debate about institutions. The few professionals who suggest any alternative reform-pass are neglected and/or discredited by the leaders of the professional field.

To sum up, while MHD&AP declared that mental health policy and services need to address the needs of the population as a whole, need to be comprehensive and integrated, covering mental health promotion, early intervention in crises, innovative community-based care and policies to achieve social inclusion (WHO 2005, X), the shift from psychiatry to mental health happened only on a rhetorical level in the Hungarian documents.